FM 1 Flashcards
anticoagulation determination for AFIB
CHA2DS2VAS
CHF---1 HTN----1 age >75---1 DM--1 Stroke, TIA, TE-----2 Vascular disease (prior MI, PAD, CABG)---1 Age 65-74----1 Sex---female---1
Score 0= no anticoag
score 1— no coag or just ASA (81-324) or OAC
score 2—- OAC
score >3—- OAC
rhythm control for AFIB
- under 48 hours
- over 48 hours
- unstable
CCB (diltiazem or verapamil)
or
BB like metoprolol
under 48 hrs: cardioversion, amiodarone (obtain transesophageal echo (TEE) to determine if a clot is present prior to cardioversion)
over 48: anticoagulate for 21 days prior to cardioversion
unstable= synch cardiov
list DOACs
direct oral anticoags
dabigatran, rivaroxaban, apixaban, or edoxaban
-ban or -an
**better than warfarin
when to give warfarin for afib
mechanical heart valves, mitral stenosis, unacceptable increase in cost, EGFR < 30 ml/min, on certain medications (phenytoin or certain antiretroviral therapy
Adjusted-dose warfarin target INR is
2.5
range=2-3
what is top picked DOACs
apixaban or Eliquis best balance of safety and efficacy,
Xarelto (rivaroxaban) for once-daily dosing
dont jump to what meds for AFIB anticoag control
ANTI PLATS
- asa
- clopidogrel
These antiplatelets aren’t as effective as an anticoagulant in reducing stroke risk in atrial fib patients…and bleeding risk may not be lower
consider what drug if CrCl is below 30 mL/min
warfarin
what is clopidogrel
antiplatelet
when would you have to lower the dose of ELiquis
if taken with Clarithromycin
Virchow triad
Stasis, hypercoaguability and trauma (like surgery)
Describe homan’s sign
Extend the leg…and then push the foot towards the head (Doris flex) and will cause pain
DVT
- diagnosis —-GS, 1st line, others
- tx
DX= 1st line is venous duplex US, D-diner (will r/o DVT in low risk PT), GOLD STANDARD= venography,
TX
- Immediate anti coagulation:
* LMW heparin + warfarin, LMWH + either Dabigatran or Eboxaban as mono therapy with Rivaroxaban or Apixaban (all DOACs) or fondaparinux, or the oral factor Xa inhibitors - IVC filter—- 3 indications
* recurrent despite adequate anticoagulation
* stable PT in whom anticoagulation is contradinicated
* right ventricular dysfunction with an enlarged RV on echo - Thrombosis is or thrombectomy: generally not done—reserved for massive DVT or severe cases
Tx for a pregnant woman with DVT
LMWH as initial and long term tx
Leg pain that worsens with walking, elevation of leg
Peripheral ARTERY disease
Leg pain that is improved with walking or elevation
PVD
Cyanotic leg with dependency
PVD
Red leg with dependency
PAD
Leg ulcers at the medial malleolus with uneven ulcer margins
PVD
Leg ulcers at lateral malleous with clean margins
PAD
Leg/foot has brownish pigmentation—— eczema toys rash, thickening of skin
PVD
Atrophic changes to leg/foot…. thin shiny skin, loss of hair, muscle atrophy, pallor, thick nails, Mottled appearance
PAD
Pericarditis
- two MCC
- CM-what makes pain better/worse
- DX
- TX *****
MCC=viral (coxsachkike virus , echovirus) and idiopathic
OTHER CAUSES= dressier syndrome (post MI + fever +pleural eff), autoimmune, uremia, bacterial, radiation, medications
CM
*sudden onset CP==sharp, worse with inspiration, persistent, postural—-worse when supine and improved with sitting forward
DX
- EKG: diffuse ST elevations in precordial leads (v1-v6) with PR depressions
- +/- cardiac enzymes
- ECHO:
TX
- NSAIDs or ASA first line x7-14 days
- Colchicine 2nd line
If dressier syndrome—> ASA or colchicine (AVOID NSAIDs bc they can interfere with Myocardial scar formation)
Sinus rate that varies with inspiration
Sinus arrhythmia
systolic-ejection murmur (SEM) heard in the second intercostal space (ICS) at the right sternal border with radiation to the carotids and the apex.
AS
Murmur is decreased with Valsalva
AS
Harsh systolic ejection crescendo-decrescendo murmur at the right upper sternal border with radiation to the neck and apex heard best by leaning forward with expiration and squatting associated with a split S2.
AS
What happens to LV with aortic stenosis
Increases after load in LV—-> LV hypertrophy
Causes of AS
Rheumatic, congenital, degenerative
A common mnemonic for aortic stenosis symptoms is
SAD
Syncope
Angina
Dyspnea
AS
-decreases and increase with>
Increases when squatting
Decreases with hand grip and Valsalva or straining of any kind
Murmur may rad to the neck or apex
AS
Murmur may rad to the neck or apex
AS
Murmur may rad to the neck or apex
AS
Helmet cells
fragmented red blood cells that can be caused by aortic stenosis due to mechanical damage of red blood cells as they pass through the calcified valves. Helmet cells are also known as schistocytes
Etiologies of AS
- Degenerative: calcification, wear and tear esp >70
- Congenital and bicuspid valve common in <70
- Rheumatic HD: isolated or also pained with AR
What can happen in peripartum period to the heart
Dilated cardiomyopathy
S/s of dilated cardiomyopathy
S3 gallop ********
Edema of LE
Lungs—- rales
JVD
Exertional dyspnea, edema, fatigue, loss of appetite, and cough
To dilated cardiomyopathy
Tx is similar to CHF
- ACEI + BB + Loop diuretic
- dig to increase contractility
- exrtreme cases= transplant or LVAD
Graves Dz
-dx
HYPERthyroid
- Primary HYperthyroid profile: Low TSH and high T3** or T4
- thyroid stimulating immunoglobulins is HALLMARK
- Radioactive uptake scan: diffuse, increased iodine uptake
Test to measure Anti-thyrotropin antibodies (TSHR-Ab).
***TSI—- thyroid stimulating immunoglobulin
Or
** TSH-binding inhibitor immunoglobulin (TBII)
Sudden ocular pain. She reports she was visiting the planetarium when the pain started and when she walked outside she saw halos around the street lights. The pain was so bad that she began to vomit. She reports her vision is decreased. Physical examination reveals conjunctival injection, a cloudy cornea, and pupils
Acute angle closure glaucoma
Tx for acute angle closure glaucoma
- 1st line
- definitive
- others
COMBO OF SYSTEMIC (IV) AND TOPICAL AGENTS
IV or PO Acetazolamide or Mannitol: the first-line agent - decrease IOP by decreasing aqueous humor production \+ timolol OR Pilocarpine, Carbachol OR Apraclonidine
Peripheral iridotomy (punches a hole in the iris) is the definitive treatment
Injected conjunctiva, cloudy cornea and fixed dilated pupil
Triad for acute narrow angle closure glaucoma
Main difference b/w s/s of iritis and acute narrow angle closure glaucoma
IRITIS—- small constricted pupil
GLAUCOMA—— fixed dilated pupil
**BOTH HAVE SIM S/S—— sudden pain, red conjunctiva, cloudy cornea etc
patient cannot wrinkle forehead
bells palsy
patient can wrinkle forehead
TIA NOT bells palsy
Two types of TIA exist:
Large artery low flow TIA (stenosis) likely carotid stenosis causing short live (minutes) decrease in flow to the brain. If the stenosis is > 70% treat surgically
Embolic TIA: emboli often form in the heart (afib)
s/s of TIA and what do the s/s correlate to which vessel
Interal Carotid: amaurosis Fugaux—monocular vision loss–temporary “lampshape down on the eye”, weakness in CONTRAlateral hand
ICA/MCA/ACA: Cerebral hemisphere dysfunction. Sudden headache, speech changes, confusion
PCA: somatosensory deficit
Vertebrobasilar: brainstem/cerebral symptoms (gait and proprioception)
Diagnostic studies for TIA
TOC for pt with suspected cardiac etiology?
Most sensitive = MRI
CT, carotid doppler to look for stenosis, CT angiography, MR angiography
-EKG to r/o AFIB
Transthoracic echocardiogram (TTE) is the preferred initial test for the majority of patients with a suspected cardiac or aortic source of emboli
Essential tremor– genetics?
autosomal dominant
so pt will have a + fam hx
when does shaking occur with essential tremor
- tremor aggrivated by?
- tremor better with?
simple tasks such as tying shoelaces, handwriting, shaving or simply holding hands against gravity
aggrivated by stress, caffiene, fatigue
better with ETOH
first line tx for essential tremor
0ther drugs
propranolol 1st line
Primidone, alprazolam, small amounts of alcohol, gabapentin, topiramate, or nimodipine
Drug-resistant cases - Deep brain stimulation
essential tremor is also called
intentional tremor
***PKD tremor is at rest
tx for animal bite
- stop any bleeding
- high pressure irrigation
- The wound should be explored under local anesthesia to assess its depth and look for foreign bodies
- Primary wound closure is indicated for superficial dog bites
- Cat and human bites aren’t closed and instead should close on their own by secondary intention due to the high risk of infection
- . Regardless of the biting mammal, a wound to the face should be closed because cosmesis is important
- tetanus prophylaxis tetanus toxoid and tetanus immunoglobulin should be considered
- wild animal bite = rabies vaccine and/or immunoglobulin
- Augmentin 875 one tab PO BID x 7-10 days***** or Clindamycin 450 mg TID + Bactrim DS 1-2 tab BID or PCN Allergy/Pregnant - Azithromycin 500 PO x 1 then 250 mg PO x 5 days
When a decision is made to close a mammal bite wound, four criteria must be fulfilled
- uninfected
- <24 hrs
- not located on hand or foot
- pt should have healthy immune system
Osteoporosis
-diagnosis tests–gs etc
TESTS:
GS: DEXA
***POST MENOPAUSAL WOMEN EVERY 2 YRS >65 yo
**POSTMEN WONEN <65 YO WTH RF OR FXS
pt is taking bisphosphonates– what do you tel htem to do right away after taking it
sit uprgith for at leat 30 min
Oral bisphosphonates must be taken on an empty stomach with a full (8-oz, 250 mL) glass of water, and the patient must remain upright for at least 30 min
list t score for osteporosis and osteopneia
porosis= < or equal to -2.5 penia= -1 to -2.5
DeXA scannig frequency based on T scores
-1.0–>-1.5
-1.5 to -2.0
greater than -2.0
T score of -1.0 to -1.5 every 5 years
T score -1.5 to -2.0 every 3-5 years
T score of greater than - 2.0 every 1 to 2 years”
PE findings for osteoarthritis
- common joints
- xray findings
bony enlargement of fingers—–DIP (herbenderbs nodes), and or bouchards nodes (PIP)
PAIN WILL IMPROVE WITH REST AND WORSEN WITH ACTIVITY********(comp to RA….. you have the morning stiffness and then improves with activity)
***morning stiffness UNDER 30 mins
***evening joint stiffness
main thing is that the pain/stiffness imrpoves with rest and worsens with use
MC hands, hips and knees
As OA progresses, joint motion becomes restricted, and tenderness and crepitus or grating sensations develop
Osteoarthritis does not involve the metacarpophalangeal joints
XRAY findings
- osteophytes: bony projections that form along joints
- joint space narrowig
- joint sclerosis: area just below the cartilage layer fills with collagen and becomes denser than healthy bone
Hypertensive crisis
- define
- crisis vs urgency
57 y/o with BP of 170/110, intermittent loss of vision right eye, and headaches—– CRISIS
crisis/emergency= evere hypertension (SBP ≥ 180 and/or DBP ≥ 120) WITH signs of damage to target organs (except papilledema which = hypertensive retinopathy) - encephalopathy, nephropathy, intracranial hemorrhage, aortic dissection, pulmonary edema, unstable angina or MI
urgency= Very high blood pressure (systolic ≥ 180 or diastolic ≥ 120) WITHOUT** target-organ damage
tx for HTN urgency and crisis/emergency
Hypertensive urgency = clonidine (drug of choice)
Hypertensive emergency = IV sodium nitroprusside (nicardipine) (drug of choice)— CCB
- ** should be used with a BB like labetalol
- **BP must be reduced in 1 hour to avoid morbidity or death
tx for BPH
- Relax the bladder/urethra: α-1 blockers - tamsulosin (Flomax) most uroselective provides rapid symptom relief - smooth muscle relaxation of prostate and bladder neck decreases urethral resistance and obstruction which increases urinary flow can cause dizziness and orthostatic hypotension as well as retrograde ejaculation
- Decrease prostate size (shrink prostate): 5 alpha-reductase inhibitors (finasteride) and (dutasteride) (androgen inhibitor - inhibits the conversion of testosterone to dihydrotestosterone suppressing prostate growth, and reducing bladder outlet obstruction) has a positive effect on the clinical course of BPH
- TURP (transurethral resection of the prostate) if refractory to meds - removes excess prostate tissue to relieve obstruction - sexual dysfunction and urinary incontinence
